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NCK Licensure Exam practice questions

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Question 1Nursing Fundamentals and Health Assessment

A nurse is assessing an adult client's radial pulse and counts 52 beats in 30 seconds. How should the nurse document the heart rate?

  1. 52 beats per minute
  2. 78 beats per minute
  3. 26 beats per minute
  4. 104 beats per minute Correct answer.

Explanation

When a pulse is counted for 30 seconds, the count is multiplied by 2 to obtain the rate per minute, so 52 × 2 = 104. Counting for a full 60 seconds is preferred when the rhythm is irregular or the rate is abnormal.

Question 2Nursing Fundamentals and Health Assessment

Which route of temperature measurement is generally considered the most reliable core-temperature estimate in an adult?

  1. Oral
  2. Temporal artery
  3. Axillary
  4. Rectal Correct answer.

Explanation

Rectal temperature most closely reflects core body temperature and is traditionally the reference site, though it is avoided in clients with diarrhea, recent rectal surgery, or neutropenia. Oral and axillary readings are affected by breathing, drinking, and environmental exposure.

Question 3Nursing Fundamentals and Health Assessment

A nurse is preparing to measure blood pressure in an adult. Which action best supports an accurate reading?

  1. Support the arm at heart level and let the client rest quietly Correct answer.
  2. Place the cuff over the client's sleeve to save time
  3. Have the client stand and hold the arm above the head
  4. Deflate the cuff rapidly regardless of the Korotkoff sounds

Explanation

The arm should be supported at the level of the heart with the client seated quietly for several minutes, because arm position above or below heart level falsely lowers or raises the reading. Cuff placement over clothing and rapid deflation both introduce measurement error.

Question 4Nursing Fundamentals and Health Assessment

Which finding should a nurse report as an abnormal respiratory pattern requiring further assessment?

  1. Cycles of deep breathing alternating with apnea Correct answer.
  2. Slight increase in rate during exercise
  3. Rate of 14 breaths per minute while resting
  4. Regular breathing at 16 breaths per minute

Explanation

Cheyne-Stokes respiration, in which periods of deep breathing alternate with apnea, signals impaired neurologic control of breathing and warrants urgent evaluation. Regular rates of 12 to 20 per minute at rest are within normal adult limits.

Question 5Nursing Fundamentals and Health Assessment

A nurse is performing a general survey at the start of a health assessment. Which element belongs to this initial phase?

  1. Observing the client's overall appearance and level of consciousness Correct answer.
  2. Testing deep tendon reflexes with a reflex hammer
  3. Palpating the abdomen for rebound tenderness
  4. Auscultating the apical pulse for one full minute

Explanation

The general survey is the first component of health assessment and focuses on observed appearance, body habitus, behavior, and level of consciousness before any hands-on examination. Palpation and auscultation belong to the physical examination that follows.

Question 6Nursing Fundamentals and Health Assessment

During auscultation of the lungs, a nurse hears soft, low-pitched, rustling sounds over most of the peripheral lung fields. How should these be documented?

  1. Vesicular breath sounds Correct answer.
  2. Bronchial breath sounds
  3. Crackles
  4. Wheezes

Explanation

Vesicular sounds are normal, soft, low-pitched sounds heard over peripheral lung tissue where air moves through smaller airways. Bronchial sounds are louder and harsher and are normally heard only over the trachea and mainstem bronchi.

Question 7Nursing Fundamentals and Health Assessment

A nurse is teaching a client about hand hygiene. Which statement indicates the client understands correct technique?

  1. I should use alcohol-based rub only when my hands are visibly soiled
  2. I should rub my hands together for about five seconds after applying soap
  3. I should wash with soap and water when my hands are visibly soiled Correct answer.
  4. I only need to clean my hands before eating meals

Explanation

Soap and water are required when hands are visibly dirty or contaminated with blood or body fluids, because alcohol rubs do not remove organic material. Otherwise, alcohol-based hand rub is preferred for routine decontamination when hands are not visibly soiled.

Question 8Nursing Fundamentals and Health Assessment

When transferring a client from bed to a chair, which action protects the nurse from injury?

  1. Raising the bed to waist height and keeping the client close Correct answer.
  2. Pulling the client upward by the shoulders
  3. Twisting at the waist while holding the client away from the body
  4. Bending forward at the hips with straight legs locked

Explanation

Raising the bed to about waist height and keeping the client close to the nurse's body reduces the lever arm and spinal load during transfer. Twisting and reaching away from the body increase shear and compressive forces on the nurse's spine.

Question 9Nursing Fundamentals and Health Assessment

A client is placed on fall precautions. Which nursing action best reflects a standard fall-prevention bundle?

  1. Placing the call light within reach and rounding regularly Correct answer.
  2. Applying physical restraints to prevent wandering
  3. Leaving the room dark at night to encourage sleep
  4. Keeping all four side rails raised at all times

Explanation

Frequent rounding and easy access to the call light address the common causes of falls, such as unassisted toileting and attempts to reach items. Restraints and raised side rails do not prevent falls and may increase injury risk.

Question 10Nursing Fundamentals and Health Assessment

A nurse is preparing to insert a peripheral IV catheter. Which action reflects surgical asepsis?

  1. Reusing the same catheter after an unsuccessful attempt
  2. Cleaning the site with an alcohol swab and fanning it dry
  3. Wearing clean gloves and palpating the site after antiseptic application
  4. Using sterile gloves and allowing the antiseptic to dry before puncture Correct answer.

Explanation

Insertion of a vascular access device requires sterile technique: sterile gloves plus an antiseptic that is allowed to dry completely before venipuncture. Palpating the prepared site with nonsterile gloves recontaminates the skin.

Question 11Nursing Fundamentals and Health Assessment

A nurse receives a prescription to administer 1,000 mL of normal saline over 8 hours by gravity infusion. The tubing delivers 15 drops per milliliter. What flow rate should the nurse set?

  1. 21 drops per minute
  2. 15 drops per minute
  3. 31 drops per minute Correct answer.
  4. 42 drops per minute

Explanation

The drop rate equals volume in milliliters times the drop factor divided by minutes: 1,000 × 15 ÷ 480 = 31.25, rounded to 31 drops per minute. Checking the calculation against the ordered infusion time confirms the setting.

Question 12Nursing Fundamentals and Health Assessment

A nurse is preparing to administer a medication through a nasogastric tube. Which action is correct?

  1. Mix all medications together to save time
  2. Crush enteric-coated tablets and administer them with the others
  3. Administer medications with the tube clamped for 30 minutes afterward
  4. Verify tube placement and flush with water before and after each medication Correct answer.

Explanation

Tube position must be confirmed before instillation, and flushing between medications prevents clogging and drug interactions within the tube. Enteric-coated and sustained-release forms should not be crushed because doing so alters absorption.

Question 13Nursing Fundamentals and Health Assessment

A nurse is assessing a client with dehydration. Which finding is most consistent with this condition?

  1. Bounding pulses and jugular venous distention
  2. Crackles in the lung bases
  3. Dry mucous membranes and poor skin turgor Correct answer.
  4. Moist mucous membranes and urine specific gravity of 1.010

Explanation

Dehydration reduces interstitial and intracellular fluid, producing dry mucous membranes, decreased skin turgor, and concentrated urine. Bounding pulses, jugular distention, and crackles instead suggest fluid overload.

Question 14Nursing Fundamentals and Health Assessment

A client reports pain rated 8 out of 10 and is grimacing and guarding the abdomen. Which initial nursing action is most appropriate?

  1. Administer the prescribed analgesic and evaluate the response Correct answer.
  2. Document the pain as mild and reassess in four hours
  3. Tell the client that pain medication is not due yet
  4. Encourage the client to distract themselves from the pain

Explanation

The nurse should act on the client's self-report and objective signs by administering the prescribed analgesic and then evaluating effectiveness. Pain is a subjective experience, and the client's rating is the most reliable indicator.

Question 15Nursing Fundamentals and Health Assessment

A nurse is assessing a client's level of consciousness using the Glasgow Coma Scale. Which three categories does the scale evaluate?

  1. Eye opening, verbal response, and motor response Correct answer.
  2. Orientation, memory, and judgment
  3. Pupil size, blood pressure, and respiratory rate
  4. Posture, gait, and coordination

Explanation

The Glasgow Coma Scale scores eye opening, best verbal response, and best motor response, with a total ranging from 3 to 15. Lower totals indicate a more depressed level of consciousness.

Question 16Nursing Fundamentals and Health Assessment

A nurse is preparing to perform a physical examination of the abdomen. Which sequence of techniques is correct?

  1. Inspect, palpate, percuss, auscultate
  2. Auscultate, inspect, palpate, percuss
  3. Inspect, auscultate, percuss, palpate Correct answer.
  4. Percuss, palpate, inspect, auscultate

Explanation

For the abdomen, inspection comes first, followed by auscultation before percussion and palpation, because manipulating the abdomen alters bowel sounds. The usual palpate-last sequence is modified here to preserve accurate auscultatory findings.

Question 17Nursing Fundamentals and Health Assessment

A nurse is assessing an older adult for pressure injury risk. Which factor most increases this client's risk?

  1. A Braden Scale score of 23
  2. Adequate dietary protein intake
  3. Regular repositioning every two hours
  4. Moisture from incontinence and reduced mobility Correct answer.

Explanation

Prolonged pressure combined with moisture and immobility breaks down skin integrity and is a leading cause of pressure injury. Higher Braden scores indicate lower risk, and repositioning and adequate nutrition are protective.

Question 18Nursing Fundamentals and Health Assessment

A nurse is caring for a client with an indwelling urinary catheter. Which action best prevents catheter-associated urinary tract infection?

  1. Disconnecting the tubing to obtain urine samples
  2. Cleaning the perineum only when the client requests it
  3. Keeping the drainage bag below the level of the bladder Correct answer.
  4. Irrigating the catheter routinely with an antibiotic solution

Explanation

Keeping the drainage bag below bladder level prevents backflow of colonized urine into the bladder. Routine irrigation and unnecessary disconnections break the closed system and introduce organisms.

Question 19Nursing Fundamentals and Health Assessment

A nurse is teaching a client with a new colostomy about caring for the stoma. Which statement by the client indicates a need for further teaching?

  1. I will cut the wafer opening to fit snugly around the stoma
  2. I will clean the stoma with mild soap and water
  3. I should apply the pouch directly over the peristomal skin without measuring Correct answer.
  4. I should expect the stoma to be beefy red and moist

Explanation

The skin barrier opening must be measured and cut to fit the stoma closely, usually about 1/8 inch larger, to protect the surrounding skin from effluent. A beefy red, moist stoma and mild soap cleansing are expected and correct.

Question 20Nursing Fundamentals and Health Assessment

A nurse is preparing to administer a subcutaneous injection of insulin. Which technique is correct?

  1. Inject slowly into the ventrogluteal site with a 1.5-inch needle
  2. Pinch the skin, insert at a 45- to 90-degree angle, and aspirate before injecting
  3. Use a 1-inch needle inserted at a 90-degree angle into the deltoid
  4. Insert at a 90-degree angle into the abdomen and release the pinch before injecting Correct answer.

Explanation

Insulin is typically given into the abdomen or other subcutaneous sites at a 90-degree angle with a short needle, and the pinch is released before injecting to avoid injecting into compressed tissue. Aspiration is not recommended for subcutaneous insulin injections.

Question 21Nursing Fundamentals and Health Assessment

A nurse is caring for a client receiving a blood transfusion when the client develops fever, chills, and flank pain shortly after the infusion begins. What is the priority action?

  1. Stop the transfusion and maintain IV access with normal saline Correct answer.
  2. Document the findings and continue monitoring
  3. Administer the next unit as ordered to complete the therapy
  4. Slow the transfusion and reassess in 15 minutes

Explanation

Fever, chills, and flank pain suggest an acute hemolytic transfusion reaction, which requires immediately stopping the transfusion and keeping the line patent with normal saline. The provider and blood bank are then notified and the reaction is investigated.

Question 22Nursing Fundamentals and Health Assessment

A client with chronic obstructive pulmonary disease has an oxygen saturation of 88% on room air. Which action reflects appropriate oxygen therapy?

  1. Administer high-flow oxygen to raise saturation to 100%
  2. Place the client flat and encourage rapid deep breathing
  3. Titrate oxygen to a target saturation, generally 88% to 92% Correct answer.
  4. Withhold oxygen because it will eliminate the hypoxic drive

Explanation

In clients with chronic hypercapnia, oxygen is titrated to a target saturation of about 88% to 92% to correct hypoxemia while avoiding excessive oxygen that can worsen carbon dioxide retention. Oxygen is not withheld from a hypoxemic client.

Question 23Nursing Fundamentals and Health Assessment

A nurse is assessing a client who is receiving a loop diuretic. Which laboratory finding most concerns the nurse?

  1. Hemoglobin of 14 g/dL
  2. Potassium of 2.9 mEq/L Correct answer.
  3. Creatinine of 0.9 mg/dL
  4. Sodium of 138 mEq/L

Explanation

Loop diuretics promote potassium excretion, and a value of 2.9 mEq/L represents hypokalemia that can precipitate dysrhythmias and muscle weakness. The other values fall within reference ranges and are not caused by diuretic therapy.

Question 24Nursing Fundamentals and Health Assessment

A nurse is assessing a client with suspected increased intracranial pressure. Which finding requires immediate intervention?

  1. Urine output of 40 mL per hour
  2. Pupils equal and reactive to light at 3 mm
  3. Blood pressure 150/60 mm Hg with widening pulse pressure Correct answer.
  4. Heart rate of 78 beats per minute and regular

Explanation

A widening pulse pressure with rising systolic pressure is part of the Cushing triad that signals increased intracranial pressure and impending herniation. The nurse should report this finding immediately and prepare for intervention.

Question 25Nursing Fundamentals and Health Assessment

A nurse is teaching a client about wound healing by secondary intention. Which statement by the client indicates correct understanding?

  1. The wound edges are brought together with sutures for rapid closure
  2. The wound heals without any scar formation
  3. The wound requires no dressing changes
  4. The wound is left open to fill with granulation tissue from the base Correct answer.

Explanation

Secondary intention occurs when a wound is left open and heals by granulation tissue filling the defect from the base upward, often leaving a larger scar. Primary intention involves approximated edges closed with sutures or staples.

Question 26Nursing Fundamentals and Health Assessment

A nurse is assessing a client's radial pulse. Which technique is correct for counting the rate when the rhythm is irregular?

  1. Count the beats for a full 60 seconds Correct answer.
  2. Count the beats for 15 seconds and multiply by four
  3. Count the beats for 10 seconds and multiply by six
  4. Count the beats for 30 seconds and multiply by two

Explanation

When the rhythm is irregular, the pulse must be counted for a full minute because beat-to-beat intervals vary, and short counts magnify error. A 30-second or 15-second count is acceptable only when the rhythm is regular. Accurate rate detection guides decisions about further assessment and reporting.

Question 27Nursing Fundamentals and Health Assessment

A nurse is measuring a client's blood pressure using the auscultatory method. Which action is correct?

  1. Ask the client to hold the arm extended and unsupported during inflation
  2. Position the cuff bladder over the brachial artery with the arm supported at heart level Correct answer.
  3. Deflate the cuff rapidly at 10 mm Hg per second
  4. Place the cuff over the client's clothing to save time

Explanation

Correct cuff placement centers the bladder over the brachial artery with the arm at heart level, which prevents hydrostatic and positional error. Clothing under the cuff and unsupported arms both distort readings. Deflation should proceed at about 2 to 3 mm Hg per second so that Korotkoff sounds are not missed.

Question 28Nursing Fundamentals and Health Assessment

A nurse is performing a cardiovascular assessment and palpates a client's apical pulse. Which landmark identifies the point of maximal impulse in most adults?

  1. Second intercostal space at the right sternal border
  2. Third intercostal space at the left anterior axillary line
  3. Fifth intercostal space at the left midclavicular line Correct answer.
  4. Fourth intercostal space at the left sternal border

Explanation

The apical impulse is normally felt at the fifth intercostal space in the left midclavicular line, where the left ventricle lies closest to the chest wall. This landmark is used both for palpating the point of maximal impulse and for auscultating the apical pulse. A displaced impulse may suggest ventricular enlargement and warrants further assessment.

Question 29Nursing Fundamentals and Health Assessment

A nurse is assessing a client's skin turgor to evaluate hydration status. Which site is most reliable in an older adult?

  1. The forearm
  2. The lower abdomen
  3. The dorsum of the hand
  4. The forehead or sternum Correct answer.

Explanation

Skin elasticity declines with age, so turgor over the hand or forearm may appear poor even when hydration is normal. The forehead or sternum retains more reliable elasticity and is preferred in older adults. Interpreting turgor together with mucous membranes and other findings improves accuracy.

Question 30Nursing Fundamentals and Health Assessment

A nurse is assessing a client and documents a positive Romberg sign. Which interpretation of this finding is correct?

  1. The client maintains balance only when visual cues are removed
  2. The client has intact proprioception and no fall risk
  3. The client loses balance when standing with eyes closed, indicating impaired proprioception Correct answer.
  4. The client has weakness of the facial muscles on one side

Explanation

The Romberg test asks the client to stand with feet together and eyes closed; a positive result is swaying or loss of balance that appears only when vision is removed. This indicates impaired proprioception or vestibular input, because the client was relying on vision to maintain balance. A positive sign raises fall risk and warrants further neurologic assessment.

Question 31Medical-Surgical Nursing

A client is admitted with a suspected small bowel obstruction. Which assessment finding is most consistent with an obstruction high in the small intestine?

  1. Fecal vomiting appearing within the first few hours
  2. Abdominal distention that develops before vomiting
  3. Copious vomiting that begins early in the course Correct answer.
  4. Absence of bowel sounds from the onset of symptoms

Explanation

Obstructions proximal in the small bowel cause early, profuse vomiting because the obstructed segment is short and cannot accommodate accumulated secretions. Distention tends to be less prominent initially than in lower obstruction, and fecal vomiting is a late sign associated with distal or prolonged obstruction.

Question 32Medical-Surgical Nursing

A client with a new ileostomy has liquid output of 1,800 mL over 24 hours. Which nursing action is the priority?

  1. Encourage a high-fiber diet to thicken stool
  2. Restrict oral intake to clear liquids for 48 hours
  3. Monitor for signs of fluid and electrolyte deficit Correct answer.
  4. Apply a tight pouch belt to reduce output

Explanation

An ileostomy output exceeding roughly 1,000 to 1,200 mL daily places the client at risk for hypovolemia and losses of sodium, potassium, and magnesium. Monitoring hydration status and electrolytes is the priority before dietary manipulation.

Question 33Medical-Surgical Nursing

Which client is at highest risk for developing a pressure injury?

  1. A client with type 2 diabetes who is alert and eats well
  2. A client with a BMI of 32 who ambulates with a walker
  3. A client who had surgery yesterday and is now walking
  4. A client with fecal incontinence who is sedated and immobile Correct answer.

Explanation

Pressure injury risk rises with immobility, moisture from incontinence, and impaired sensory awareness from sedation. The combination of these factors creates sustained pressure and skin maceration that markedly increase risk.

Question 34Medical-Surgical Nursing

A client is 12 hours after a total thyroidectomy and reports tingling around the mouth and fingertips. Which action should the nurse take first?

  1. Check the serum calcium level and notify the provider Correct answer.
  2. Encourage the client to breathe into a paper bag
  3. Administer a prescribed opioid for pain
  4. Prepare for emergency tracheostomy

Explanation

Perioral and digital paresthesias after thyroidectomy suggest hypocalcemia from inadvertent parathyroid injury. Confirming serum calcium and notifying the provider guides prompt calcium replacement before tetany or laryngospasm develops.

Question 35Medical-Surgical Nursing

A client with chronic kidney disease has a serum potassium of 6.8 mEq/L. Which prescribed intervention should the nurse anticipate implementing first?

  1. Restricting dietary potassium for 24 hours
  2. Giving oral sodium polystyrene sulfonate
  3. Administering intravenous calcium gluconate Correct answer.
  4. Scheduling the next hemodialysis session

Explanation

Severe hyperkalemia threatens cardiac conduction, so membrane stabilization with intravenous calcium is the immediate priority when ECG changes are present. Potassium-lowering therapies follow once the myocardium is protected.

Question 36Medical-Surgical Nursing

A nurse is teaching a client about a low-purine diet after a gout flare. Which food should the client limit?

  1. Organ meats such as liver Correct answer.
  2. Fresh apples
  3. Low-fat yogurt
  4. White rice

Explanation

Purines are concentrated in organ meats, sardines, and shellfish, and their breakdown raises uric acid. Limiting these foods reduces the risk of recurrent gout flares.

Question 37Medical-Surgical Nursing

A client is receiving intravenous heparin. The aPTT is 110 seconds and the client has new hematuria. Which action should the nurse take?

  1. Recheck the aPTT in six hours
  2. Stop the infusion and notify the provider Correct answer.
  3. Give the next scheduled dose as ordered
  4. Increase the infusion to maintain therapeutic range

Explanation

An aPTT far above therapeutic range with active bleeding indicates over-anticoagulation. The infusion must be stopped and the provider notified, with protamine sulfate anticipated as the antidote.

Question 38Medical-Surgical Nursing

Which finding should the nurse report immediately in a client receiving a blood transfusion?

  1. Urticaria and wheezing developing minutes into the infusion Correct answer.
  2. Gradual decrease in hemoglobin after transfusion
  3. Mild itching at the venipuncture site
  4. Temperature rise of 1.8 degrees Fahrenheit after one hour

Explanation

Urticaria with wheezing suggests an anaphylactic or severe allergic transfusion reaction requiring immediate cessation of the transfusion and emergency treatment. Airway involvement distinguishes it from a mild febrile reaction.

Question 39Medical-Surgical Nursing

A client with an acute exacerbation of asthma has a respiratory rate of 34 and speaks in single words. Which finding indicates impending respiratory failure?

  1. Loud wheezing throughout both lung fields
  2. Use of accessory muscles
  3. Oxygen saturation of 94 percent on room air
  4. Silent chest with minimal air movement Correct answer.

Explanation

A silent chest signals such severe airflow obstruction that air movement is minimal, a preterminal sign of respiratory failure. Wheezing and accessory muscle use reflect effort, but silence indicates the effort is failing.

Question 40Medical-Surgical Nursing

A client is admitted with diabetic ketoacidosis. Which laboratory pattern should the nurse expect?

  1. pH 7.38, bicarbonate 24 mEq/L, glucose 140 mg/dL
  2. pH 7.30, bicarbonate 26 mEq/L, glucose 90 mg/dL
  3. pH 7.48, bicarbonate 30 mEq/L, glucose 320 mg/dL
  4. pH 7.20, bicarbonate 12 mEq/L, glucose 480 mg/dL Correct answer.

Explanation

DKA produces a high anion gap metabolic acidosis with low pH and low bicarbonate due to ketone accumulation, along with marked hyperglycemia. The other patterns describe alkalosis or normal values.

Question 41Medical-Surgical Nursing

A client with a spinal cord injury at T4 suddenly reports a pounding headache and has a blood pressure of 210/120 mm Hg. Which action should the nurse take first?

  1. Perform a bladder scan after 30 minutes
  2. Administer a prescribed antipyretic
  3. Raise the head of the bed to a high-Fowler position Correct answer.
  4. Document the finding and reassess later

Explanation

This presentation suggests autonomic dysreflexia, a hypertensive emergency triggered by noxious stimuli below the injury level. Sitting the client upright promotes venous pooling and lowers blood pressure while the trigger, often bladder distention, is identified.

Question 42Medical-Surgical Nursing

A client with heart failure is prescribed furosemide. Which laboratory value should the nurse monitor most closely?

  1. Platelet count
  2. Serum creatinine only
  3. Serum potassium Correct answer.
  4. Hemoglobin

Explanation

Loop diuretics increase renal potassium excretion and can cause hypokalemia, which predisposes to dysrhythmias, especially in clients taking digoxin. Potassium monitoring is therefore a priority.

Question 43Medical-Surgical Nursing

A client is one day after an abdominal surgery and reports sudden shortness of breath and chest pain. Which action should the nurse take first?

  1. Ambulate the client in the hallway
  2. Encourage the client to drink fluids
  3. Apply supplemental oxygen and notify the provider Correct answer.
  4. Reposition the client onto the abdomen

Explanation

Sudden dyspnea and pleuritic chest pain after surgery suggest pulmonary embolism. Oxygen and prompt provider notification are immediate priorities while anticipating diagnostic imaging and anticoagulation.

Question 44Medical-Surgical Nursing

A client is receiving total parenteral nutrition through a central line. Which action is most important to prevent a complication?

  1. Flush the line with sterile water
  2. Increase the infusion rate to catch up when late
  3. Check blood glucose levels regularly Correct answer.
  4. Change the tubing every 72 hours

Explanation

Total parenteral nutrition contains high concentrations of dextrose and can cause hyperglycemia, so glucose monitoring is essential. Abrupt rate changes and improper flushing also create risk but glucose control is the central ongoing concern.

Question 45Medical-Surgical Nursing

A client with cirrhosis has ascites and is prescribed spironolactone. Which finding indicates a therapeutic response?

  1. Decreased urine output
  2. Increase in abdominal girth with stable weight
  3. Rising serum potassium to 6.2 mEq/L
  4. Weight loss of 1 kg per day with reduced abdominal girth Correct answer.

Explanation

Gradual weight loss of about 0.5 to 1 kg daily with decreasing abdominal girth reflects effective diuresis of ascites. Rapid or excessive diuresis risks hypovolemia and renal impairment.

Question 46Medical-Surgical Nursing

Which client statement indicates correct understanding of a newly prescribed warfarin regimen?

  1. I will keep my intake of leafy green vegetables consistent. Correct answer.
  2. I can take aspirin for headaches without asking.
  3. I will stop the drug once my leg swelling resolves.
  4. I will double my dose if I miss one day.

Explanation

Vitamin K-rich greens affect warfarin's International Normalized Ratio, so consistent rather than eliminated intake is recommended. This keeps anticoagulation predictable.

Question 47Medical-Surgical Nursing

A client with a new colostomy asks how to care for the stoma. Which instruction is appropriate?

  1. Scrub the stoma vigorously with soap to remove mucus
  2. Clean the stoma gently with warm water and pat dry Correct answer.
  3. Apply alcohol to the stoma to prevent infection
  4. Cover the stoma with a dry gauze between pouch changes

Explanation

A stoma is fragile mucosa and should be cleaned gently with warm water, then patted dry before applying the pouch. Vigorous scrubbing or alcohol damages tissue.

Question 48Medical-Surgical Nursing

A client with a femur fracture develops sudden confusion, dyspnea, and a petechial rash on the chest. Which complication should the nurse suspect?

  1. Compartment syndrome
  2. Deep vein thrombosis
  3. Hypovolemic shock
  4. Fat embolism syndrome Correct answer.

Explanation

The triad of respiratory distress, neurologic changes, and a petechial rash after a long bone fracture strongly suggests fat embolism syndrome. It typically appears 24 to 72 hours after injury.

Question 49Medical-Surgical Nursing

A client is receiving morphine for postoperative pain and has a respiratory rate of 8 breaths per minute. Which action should the nurse take first?

  1. Stimulate the client and withhold further opioid Correct answer.
  2. Administer the next scheduled dose
  3. Encourage the client to drink coffee
  4. Document the rate and recheck in one hour

Explanation

A respiratory rate of 8 suggests opioid-induced respiratory depression. Stimulating the client and withholding the opioid are immediate steps, with naloxone prepared if breathing does not improve.

Question 50Medical-Surgical Nursing

A client with chronic obstructive pulmonary disease has an oxygen saturation of 86 percent. Which oxygen delivery approach is appropriate?

  1. High-flow oxygen at 10 L/min by mask
  2. Intermittent oxygen only during meals
  3. Titrated low-flow oxygen to a target saturation of 88 to 92 percent Correct answer.
  4. No oxygen because it will eliminate the hypoxic drive

Explanation

In COPD, oxygen is titrated to a target saturation of about 88 to 92 percent to correct hypoxemia while avoiding hypercarbia. Uncontrolled high-flow oxygen can worsen carbon dioxide retention.